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1. Alexander F, French T Psychoanalytic Psychotherapy. New York, The Ronald Press, 1946.la . Beck AT: Cognitive therapy for depression and panic disorder. Western J Med 151 9-89, 1989.2. Beck S , Greenberg R: Brief cognitive therapies. Psychiatr Clin North Am 2: 1-22, 1979.2a. Book H E How to Practice Brief Psychodynamic Psychotherapy: The Core Conflictual Relationship Them e3.4.56 .7.8.9.10.I
12.13.14.15.16.17.18.19
Method. Washington, DC, American P s~ ch ol og ic ~lssociation Press, 1998.Budman S , Gurman A: Theory and Practice of Brief Therapy. New York, Th e Guilford Press, 1988.Burk J White H, Havens L: Which sho rt-term therapy? Arch Gen Psychiatry 36: 177-1 86, 1989.Davanloo H: Short-Term Dynam ic Psychotherapy. New York, Jason Arons on, 19 80.Ferenczi S , Rank : The Development of Psychoanalysis. New York, Nervous and Mental DiseaseFlegenheime r W: History of brief psychotherapy. In Horner A ed): Treating the Neurotic Patient in BriefGoldin V Problems of technique: In Horner A ed): Treating the Neurotic Patient in Brief Psychotherapy.Groves J : Essential Papers on Short-Term Dynamic Therapy. New York, New York University Press, 1996.Groves J : The short-term dynamic psychotherapies: An overview. In Rutan S ed): Psychotherapy for theHall M, Arnold W, Crosby R: Back to basics: The importance of focus selection. Psychotherapy 4578-584,Horner A : Princip les for the therapist. In Horner A ed): Treating the Neurotic Pa tient in BriefHorath A, Luborsky L: The role of the therapeutic alliance in psychotherapy. J Consult Clin Psycho1Klerman G , Weissman M, Rounsaville B, Chevron E : Interpersonal Psychotherapy of Depression. NewLeibovich M : Short-term psychotherapy for the borderline personality disorder. Psychother Psychosom
Malan D: The Frontier of Brief Psychotherapy. New York, Plenum M edical Book C ompany, 1976.Mann J: Time-Limited Psychotherapy. Cam bridg e, Harvard University P ress, 1973 .Olfson M , Pincus H A: Outpatient psychotherapy in the United States. 11: Patterns of utilization. Am JSifneos P: Short-Term Anxiety Provoking Psychotherapy: Treatment Manu al. New York, Basic Books,
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44. MARITAL A N D FAMILY TH ER APIESMargaret Roath, M.S .W . , LCSW
1. What a re marital and family therapies?Marital and family therapies are therapeutic modalities whose focus of assessment and treat-ment is on the relationship, not on the individual. Assessment includes gathering data related to thefollowing areas:History of the relationshipGoals of the individuals in the relationshipCoping mechanisms which have beenPrecipitant for seeking therapy--why now?
Communication patterns, bothconstructive and destructiveDescription of the strengths ofUnmet needs of the individualsunsuccessful the relationshipor what changed? in the relationshipAssessment of the precipitant for seeking marital or family therapy is especially important in deter-mining the relationship equilibrium-which may have worked previously for all members of therelationship, but is now out of balance. The precipitant might be a change in external circumstancesor a change within an individual that is affecting the relationship.
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Marital and Family Therapies 227Marital and family therapies identify these changes and then examine patterns of communica-tion, behavior, and coping mechanisms which may have been destructive, not constructive, in re-sponding to the identified changes. The goal of therapy is to provide the marriage and the familywith new ways of responding that are helpful and constructive to the relationships. Sometimes, there
is n o acute precipitant to the request for marital or family therapy, but instead there are long-standingdestructive patterns of communication that have been identified, and the married couple or thefamily are interested in changing those patterns.2 What are the indicators for m arital and family therapies?Statements or complaints expressed by individuals that reflect concerns about the relationshipand also show the inability to resolve those concerns. Indications might include internal and externalchanges within individuals in the relationship or changes within the relationship itself.
Internal and External Indicators for Marital and Family TherapyINTERNAL CHANG ES EXTERNAL CHANG ES
A person, through individual therapy or throughlife experience, is making a decision aboutwhether to remain in the relationshipA person, through experience or therapy, realizesthat he or she is of a different sexualorientation than originally believedA person may be experiencing an internal crisis,such as a mid-life crisis, and desires to changeor maybe end the relationshipNormal developmental changes of children, suchas adolescenceDevelopmental changes of adults, such as the
Recently diagnosed illness of one of the marital orfamily members-the illness may mean death oradjustment to changing abilitiesChange in financial status through loss of a job or adecrease in payAddition of members to the mamage or family: thebirth of a child, an in-law or children of a previousmarriage joining the familyChildren leaving home, which may exacerbate un-resolved relationship issues for the mamageA decision to divorce which causes all relationshipsto be renegotiatedife desiring to return to a career after beinga homemaker
3 What treatment m odels are used for marital and fam ily therapies?In the most common model fo r marital therapy both partners of the marriage are seen togetherby one therapist. Sometimes one or both partners will also be in individual therapy. In preparationfor the marital sessions, the individuals may be working on issues pertinent only to themselves ordeveloping a better understanding of their needs as partners in a marriage. It is usually optimal forthe individuals therapist not to be the couples therapist because the therapist may learn secretswhich would compromise the marital therapy. However, when it is not possible or deemed optimalfor separate therapists for each treatment modality e.g., in rural areas), the therapist and the patientsmust establish clear boundaries regarding the content discussed in each treatment modality. Whenseveral therapists are involved, communication among them can be helpful to clarify that they areworking together and not at cross-purposes. Confidentiality needs to be addressed by each therapistwith their respective patient or patients.In the most common modelfor family rkerupy all members of the immediate family are seen to-gether. Concurrent individual therapy should be handled as noted above for marital therapy.Group therapy is another possible modality for both marital and family therapy. It affords thepossibility of learning from others in similar situations and also the benefit of feeling less alonewith the issues being addressed. Couples and families often can listen and integrate advice fromothers in similar situations better than they can integrate advice from therapists. A disadvantage isthat each couples or familys specific issues may take longer to address because time is spent ondeveloping relationships among couples or families. The therapists role is to facilitate interactionamong participants.
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228 Marital a n d Family Therapies4 What is the role of the therapist in marital and family therapies?Typically quite active. Th e therapist assists marriage and family mem bers in defining the prob-
lem and determining goals to address it. Th e therapist may need to stop certain behaviors and en-courage others within therapy-for exam ple, stopping one person from doing all of the talking andencouraging another to talk more. He or she also may have to direct marriage and fam ily members tostop certain behaviors outside of the treatment session, such as marathon discussions which mightescalate into arguments or physical actions. The therapist m ight sug gest a time limit for all discus-sions which have not resolved an issue, and also set very specific rules prohibiting physical violence,both in and out of therapy. W hen individuals in a marriage or family cannot stop physical violence, aseparation with strict guidelines for being together may be suggested.The therapist also reframes problems or feelings among marriage and family members by re-moving labels of good and bad and m aking statements about differences am ong the members. He orshe may suggest problem-so lving with the directive that if the solution is not effective, it only meansthat the participants, including the therapist, did not have all of the information necessary to developa better solution. The therapist may give homework to the marriage and family mem bers so that thetherapy does not just take place in the office, but also becom es a part of daily hom e life. The thera-pist may serve as coach educator or mentor to the m am ag e and the family when destructive com-munication is observed, by giving specific examples of what to say or by participating inrole-playing. The therapist joins with the marriage partners an d the family to develop new copingmechanisms, communication skills, and negotiation skills to address the identified problems.5. What assessment and treatment techniques are used by the therapist?The techniques of marital and family therapy focus on the relationships and relationship issues.
Assessment TechniquesAsk each individual to describe their sense of the problem and its historyAsk each individual the sam e question that has been asked of anotherIdentify nonverbal communicationAsk each individuals reaction to what another has saidIdentify them es com mo n to the relationship and individuals within that relationshipAsk individuals to speak with I phrases, not you phrases, which sound accusatoryAsk that each expressed need be accom panied by a proposed solutionAssign hom ework or tasks that respond to the assessed problemClarify-repeat what the othe r said and ask if the repeated statement was heard as intended
Many other techniques exist. Their common goal is strengthening the marriage or the familys
Treatment Techniques
bond even when the individuals feel polarized, disappointed, and an gered at the time of therapy.6. How long does marital or family therapy take?It is not possible to say specifically. However, i t is possible to establish sp ecific goals andassess at the end of each session or after an agreed-upo n num ber of sessions whether the goalshave been met and wha t will need to happen for any remaining goals to be met. Th e length of timeneeded d epends on how much blame is present, how mu ch desire or ability there is for the partici-pants to move from blam e to identification and problem solving, and how m uch em pathy all mem-bers have for other marriage and family mem bers. The m ore blaming, the less problem -solving
behavior, and the less empathy, the long er the therapy will take. Th e more willing eac h individualis to exam ine his o r her behavior and d evelop solutions for changing it , the less time therapy islikely to take.7. Are there any patients with specific psychiatric diagnoses who should not be referred to
marital or family therapy?Yes. If on e mem ber of a marriage or fam ily is psychotic or so severely depressed that he or sheis unable to focus cognitively on m arriage and family issues, then such therapy is not recomm ended.
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Marital and Family Therapies 229Once treatment fo r psychosis or depression has occurred , however, there can be a referral fo r mar-riage or family therapy if the issues identified indicate the need for it. Otherwise, because marriageand family therapies focus on changes in behavior, coping m echanisms, and problem-solving, theyhave the potential to be successful if the members are motivated to pursue those chan ges, irrespec-tive of the members DSM-IV diagnoses. Som e research shows that marital and family problemsmay increase vulnerability to m ood disorders, and those same problems m ay slow recovery or causeexacerbations of additional episodes of severe illness. Treatment to promote marital and family har-mony may prevent recurrences of the illness.Family therapy may be very helpful in reducing severity or relapses for persons with schizo-phrenia. Family members often respond positively to information about mental illness and copingstrategies and feel less alone w hen professionals are interested in working with them in managem entand caretaking. Partners and families of schizophrenics usually identify relapses earlier than the pa-tient does ; if they are working collaboratively with professionals, they can provide data that increaseservices being provided. Also, partners and families who have a positive relationship with profes-sionals and are able to express their feelings and worries in marital and family therapy sessions areless likely to be intrusive or hovering, possibly causing the patient to express hostility and anger,which could precipitate a relapse. The intrusive or hovering behavior is referred to as expressed-emotion behavior.The greater the level of this behavior, the more likely a relapse by the patient; thelower the level, the less likely.8 Can marital and family therapies be effective if one of the members is resistant?If one of the members displays resistance by not attending meetings, the issues in the marriageand the family may still be addressable, but with the understanding that the only ones who canchange behavior are those willing to attend meetings. The ocus cannot be on the person not presentIf the resistant person attends the meetings, it may be possible to lessen the resistance by having
everyone listen to and understand the reasons for the resistance. If an individual maintains resis-tance, a decision can be made for that person not to attend, and therapy can proceed fo r those mem-bers wh o are motivated.9 Are marital and family therapies different for different cultures races ages and sexual
orientations?No. The assessment process remains the same, as does the treatment process. In other words, as-sessment and treatment always focuses on needs, expectations, complementarity of roles, communi-cation, and behavior patterns. However, cultural differences between individuals in a marriage or afamily may lead to different goals or expectations, and those differences need t o be elucidated andclarified by the therap ist.10. Does there have to be a match with the therapist in the areas of culture race age andsexual orientation?
No, although coup les and families do request it. Accomm odating that request m ay facilitate thebeginning process of therapy. However, it is not necessary because a com petent therapist add ressesthe lack of complementarity in the beginning, which creates alliance-building.The alliance encour-ages the members of a marriage or family to express feelings, either negative or positive, about thelack of complementarity and allows the therapist to empathize w ith those feelings. Th e therapist alsomay encourag e the couple or family to share inform ation about culture, history, traditions, or life-style as a way to bridge the gap between those differences.11. Are marriage and family therapies always successful in keeping marriage and family to-gether and improving the relationships?No. Approximately 50 of the marriages that enter marital therapy end in separation or di-vorce. Som e couples come to marital therapy when ang er has created too great a distance and one,if not both, partners have alread y decided on separ ation or divorce. The therapy can be a forumthrough which to accomplish this goal. Sometimes one partner is hoping the other will connect
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230 Marital and Family Therapieswith the therapist as a source of support in order to feel less guilty or fearful about abandoningthe partner.Marital and family therapies are som etimes unable to promo te change because the desire tochange and enter into the unknown is weaker than the comfort of the known. The therapist sharesthat observation with a marriage and family in a nonjudgmental way, encouraging th em to returnshould the situation c hang e. Som e marriages and fam ilies exp erienc e several attempts at therapybefore they decide to m ake changes and risk the unknow n. Part of the process in marital and familytherapy is learning whether the members of a marriage or family can meet the needs expressed. If,through therapy, it is learned that needs cann ot be met, decisio ns may be required to meet thoseneeds other than through the marriage or family.12. What are some of the controversial issues?The biggest issue today is Who are the family members?when the therapist is making deci-sions such as who to invite to family therapy sessions. Th e divorce rate has altered the com positionof family systems and re lations hips. Th ere may be par ents, step-p arents, childr en, step-children,half-siblings, grandparents, and step-grandparents. There also are gay an d lesbian couples who mayhave ex-spouses by previous marriages. Children of those marriages will most likely be sharing timewith both their hom osexual and heterosexu al parents. Another recent social pheno meno n is thechoice being made by both m en and women to have children outside of m arriage. Children of suchrelationships may be living with both biologic parents, a single parent, o r one biologic parent and asignificant other of that biologic parent.Another controversial is sue is whether cou ples and fam ilies dealing with domestic violenceshould be treated w ith marital or fam ily therapy. Som e professionals say Never, because they be-lieve that marital and family therapies support blaming the victim. Tho se professionals say that onlythe perpetrator needs to be in therapy ; how ever, the basic tenet of couples therapy is that both peoplecontribute to destructive behavior. Other professionals argue that the dom estic violence o ccurred inthe context of a relationship and that the mo st helpful treatment program is individual help for theperpetrator in addition to therapy that addresses marital or family relationships. It may be that thedecision should not be viewed as either-or, but rather as a clinical decision that depends onwhether or n ot the goal is to reunite the cou ple or family.
BIBLIOGRAPHYI Balcom D, Lee R, Tager J: The systemic treatment of shame in couples. J Marital Family Ther 215 -6 5 ,2. Beck RL: Redirecting the blaming in marital psychotherapy. Clin SOCWork J 15:148-158, 1987.3. Berg K1, Jaya A: Different and same: Family therapy with Asian-American families. J Marital Family Ther4. Carter B, McG oldrick M: The Changing Family Life Cycle, A Framework for F a ~ i il y herapy. New York,5 Cordova J Jacobson N, Christensen A : Acc eptance versus cha nge intervention s in behavioral couple ther-6. Dattilio F, Padesky C: Cognitive Therapy with Couple s. Sarasota, FL, Professional Resource Exchange,7 . Gottman J Notarins C, Gonso .IMarkman H: A C ouples G uide to Comm unication. Champaign, IL,8. Greenspan R: Ma rital therapy w ith couples whose lack of self-sustaining function threatens the marria ge.9. Guerin PP, Fayu L, Burden S, Kautto G: The Evaluation a nd Treatment of M arital Con flict. New York, Basic
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10 Gurman A , Kriskern D: Handbook of Family Therapy. New York, Brunner/Mazel, 1981,I I Hugen B: T he effectiveness of a psychoeducational support service to fam ilies of persons with a chronic12. Marley J : Conten t and context: Working with mentally i l l people in family therapy. Soc Work 37:412-417,13. Molta D: Bipolar disorder and the family: An integrative model. Family Process 3 2: 40 94 23 , 1993.
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